Download UnitedHealthcare`s Approach to Covering Prenatal Office Visits

Preventive Care Services | Snapshot
UnitedHealthcare’s Approach to Covering
Prenatal Office Visits
Preventive care services and health screenings have been important to
UnitedHealthcare’s focus on helping our members identify potential health risks
and providing proactive assistance, so they may live the healthiest life possible.
We want to share our rationale for covering certain prenatal services as
preventive benefits with no cost-sharing for members. UnitedHealthcare covers
the following prenatal services without cost-sharing:
•
Routine prenatal obstetrical office visits
•
All lab services explicitly identified in the Patient Protection and
Affordable Care Act
•
Tobacco cessation counseling specific to pregnant women
•
Immunizations recommended by the Advisory Committee on
Immunization Practices
•
Counseling for breast-feeding and equipment (breast pumps) and
supplies
•
Gestational diabetes screening
Well-woman visits and prenatal care
Under the health reform law, the expanded list of women's preventive care
services requires non-grandfathered health plans to cover well-woman visits
for women "to obtain recommended preventive services that are age and
developmentally appropriate, including preconception and prenatal
care." According to the Department of Health and Human Services (HHS),
"several visits may be needed to obtain all necessary recommended preventive
services, depending on a woman's health status, health needs and other risk
factors." See http://www.hrsa.gov/womensguidelines/
Industry research and guidelines
The HHS guidelines for coverage of women’s preventive services were
developed by the Institute of Medicine (IOM). The IOM specifies that “Another
type of well-woman preventive care visit is the routine prenatal care visit for
pregnant women.”
Currently, the American Congress of Obstetricians and Gynecologists (ACOG) and the American
Academy of Pediatrics (AAP) provide guidelines on routine prenatal care visits.
See http://www.nap.edu/catalog.php?record_id=13181
UnitedHealthcare will cover without member cost-sharing routine prenatal office visits that
follow the ACOG and AAP guidelines. Delivery and postpartum care will be processed under the
maternity benefit with cost-sharing, if applicable.
If a patient is seen more than the typical antepartum visits due to high-risk or complications of
pregnancy, these visits are not considered routine and, per ACOG coding guidelines, should only
be billed when a problem develops. Accordingly, non-routine visits will not be paid as preventive
and cost-sharing may apply.
Beyond well-woman visits
Beyond the well-woman office visit, only those specific tests and screenings required by the
health reform law will be covered under the preventive benefit without cost-sharing (e.g., anemia
screening, gestational diabetes screening, HIV screening, approved vaccinations, bacteriuria
screening, hepatitis B screening, Rh incompatibility screening). Tests and screenings not
identified under the law as preventive will be adjudicated according to the terms of the plan with
cost-sharing applied as appropriate.
We defer to the member and her doctor to decide the number of routine prenatal office visits that
are necessary.
Out-of-network services may have cost-sharing
The health reform law does not require plans and issuers to cover preventive care services,
including expanded women’s preventive services, received from out-of-network providers. If a plan
covers out-of-network preventive services, the plan or issuer may impose cost-sharing
requirements, unless an applicable state law otherwise requires first-dollar coverage. If a plan does
not cover out-of-network preventive services, then out-of-network preventive services generally
will not be covered.
Out-of-network prenatal office visits
If a plan does not cover out-of-network preventive services, but does have out-of-network medical
benefits, then UnitedHealthcare will cover out-of-network routine prenatal office visits under the
plan’s out-of-network medical benefits. Any cost-sharing under the out-of-network medical
benefit would apply to the prenatal office visits.
UnitedHealthcare applies this approach because we believe prenatal care is important to
supporting the health of women and children and is consistent with our clinical quality and
affordability goals. We believe that expanding access to prenatal care is the intent of the health
reform law, and so our standard approach is to not impose new restrictions on prenatal
visits. Prior to the health reform law, UnitedHealthcare covered prenatal office visits under the
out-of-network medical benefits, and we continue this approach today even though the health
reform law does not require it. Today, this approach is only applied to routine prenatal office
visits.
Self-funded customers encouraged to follow our approach
While not required under the law, self-funded customers are encouraged to follow our approach.
If there are no out-of-network preventive benefits under the plan, self-funded customers may
request that routine prenatal office visits not be covered under the out-of-network medical benefit.
If self-funded customers choose not to cover routine prenatal office visits under the out-ofnetwork medical benefit (assuming out-of-network preventive coverage is not offered), we
strongly suggest customers inform their employees of this change in coverage as this may be a
reduction in benefits for members, depending on the plan’s design prior to health reform.
References
UnitedHealthcare has considered a significant amount of industry research to determine which
services it will cover without member cost-sharing under the expanded list of women’s
preventive care services outlined in the health reform law.
1. Institute of Medicine Report “Clinical Preventive Services for Women: Closing the
Gaps” pg. 132-133. “Another type of well-woman preventive care visit is the routine
prenatal care visit for pregnant women. AAP [American Academy of Pediatrics] and
ACOG [American Congress of Obstetricians and Gynecologists] currently recommend
the following visit schedule for women with an uncomplicated pregnancy: a visit every 4
weeks for the first 28 weeks of pregnancy, a visit every 2 weeks until 36 weeks of
pregnancy, and weekly visits thereafter (ACOG, 2007c). Women with high-risk
pregnancies may need more frequent visits.”
http://www.nap.edu/catalog.php?record_id=13181
2. Institute of Medicine
http://www.iom.edu/Reports/2011/Clinical-Preventive-Services-for-Women-Closingthe-Gaps/Recommendations.aspx
Includes chart with Recommendation 5.8 which states:
"At least one well-women preventive care visit annually for adult women to obtain the
recommended preventive services, including preconception and pre-natal care. The
committee also recognizes that several visits may be needed to obtain all necessary
recommended preventive services, depending on a woman's health status, health needs,
and other risk factors."
3. Press release: IOM Report Recommends Eight Additional Preventive Health
Services to Promote Women's Health
http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=13181
4. Healthcare.gov site which references the IOM guidelines as adopted
http://www.healthcare.gov/law/resources/regulations/womensprevention.html
The Health Resources and Services Administration-supported health plan coverage
guidelines for women’s preventive services below, developed by the Institute of
Medicine (IOM), will help ensure that women receive a comprehensive set of preventive
services without having to pay a copayment, co-insurance, or a deductible. HHS
commissioned an IOM study to review what preventive services are necessary for
women’s health and well-being and should be considered in the development of
comprehensive guidelines for preventive services for women. HRSA is supporting the
IOM’s recommendations on preventive services that address health needs specific to
women and fill gaps in existing guidelines.
Also references:
Well-woman visits: Annual, although HHS recognizes that several visits may be needed
to obtain all necessary recommended preventive services, depending on a woman’s health
status, health needs, and other risk factors.
For more information
Consult your UnitedHealthcare representative if you have questions about well-woman
visits and the expanded list of women’s preventive care services. Or, visit the United for
Reform Resource Center at uhc.com/reform and click the preventive services provision for
the latest health reform news, a link to the Coverage Determination Guideline, educational
videos, timelines and frequently asked questions about health reform. Information about
what women’s preventive services are covered under the health reform law is found at
http://www.healthcare.gov/law/resources/regulations/womensprevention.html
The content provided is for informational purposes only and does not constitute medical advice.
Decisions about medical care should be made by the doctor and patient. Always refer to the plan
documents for specific benefit coverage and limitations or call the toll-free number on the back of
the ID card.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its
affiliates. Administrative services provided by United HealthCare Services, Inc., or its affiliates.
This communication is not intended, nor should it be construed, as legal or tax advice. Please
contact a competent legal or tax professional for legal advice, tax treatment and restrictions.
Federal and state laws and regulations are subject to change.
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©2014 United HealthCare Services, Inc.